ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Nahihirapan huminga si lola dahil sa plema, as verbalized by the patient relative. Objective: productive cough sputum is thick and brownish in color crackles DOB Deep breathing irritability

Ineffective Airway Clearance related to presence of Secretions secondary to Community acquired pneumonia

After 2 hours of nursing interventions, the clients respiration will improve and difficulty of breathing will be Relieved.

Monitor RR, taking note of the depth and rate, BP, PR Auscultate lung fields, noting presence of adventitious breath sounds Elevate head of bed to high fowlers

To establish baseline data and monitor changes To determine possible bronchospasm or obstruction To facilitate breathing and lung expansion To facilitate in the expulsion of mucus

After 2 hours of nursing intervention, goal was not met as evidenced by an increase in the depth and rate of respirations due to an increase in difficulty of breathing.

Provide health teachings regarding coughing and deep breathing exercise. Encourage client to increase fluid intake to about 2000 mL Administer medications such as expectorants as ordered

To liquefy secretions

To reduce bronchospasm and mobilize secretions

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective : Nanghihina si lola as verbalized by the patient relative. Objective: Ineffective cough Restlessness Use of accessory muscles when breathing Loss of appetite Poor muscle tone

Imbalanced nutrition: less than body requirements related to inadequate intake of nutritious foods secondary to underlying disease as evidenced by loss of appetite and body weakness.

OBJECTIVE: After 5 hours of nursing intervention, the patient will regain body strength and loss of appetite will be relieved. GOAL: At the end of the nursing rotation, the patient will demonstrate behaviours, to regain or and or maintain appropriate weight.

Determine clients ability to chew, swallow, and taste food. Assess drug interactions, disease effects, allergies. Auscultate bowel sounds. Note characteristics of stool (color, amount, frequency etc.) Evaluate total daily food intake. Obtain diary of calorie intake, patterns and times of eating. Emphasize importance of well-balanced nutritious intake.

To determine factors that can affect ingestion and digestion of nutrients. To determine factors that may affect appetite, food intake or absorption. To evaluate degree of deficit

After 5 hours of nursing intervention, the patient regained body strength and loss of appetite has been relieved.

V/s

BP- 140/80 mm/Hg T -36.6 C P- 102 bpm R -41 cpm

To reveal possible cause of malnutrition/change s that could be made in clients intake. To promote wellness

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective : none Objective: V/S BP: 140/80 mmHg T: 36.6 C P: 100 bpm R: 44 cpm With AB With ET DOB Restlessness Irritability

Impaired gas exchange related to ventilation perfusion imbalance.

After 8 hours of nursing intervention the patient will be able to: 1. Demonstrate improved ventilation and adequate oxygenation of tissues by HBGs within clients normal limits. 2. Participate in treatment regimen (e.g., breathing exercises, effective coughing, and use of oxygen) within level of ability/situation. 3. Verbalize understanding of causative factors and appropriate intervention.

Independent: 1. Elevated head of bed/position client appropriately, provide airway adjuncts and suction as indicated. 2. Encouraged frequent deep breathing/ coughing exercises. 3. Auscultated breath sounds noting crackles, wheezes

Independent: 1. To maintain airway

Goal -Met: After 8 hours of nursing intervention the patient was able to demonstrate improved ventilation and

2. Promotes optimal chest expansion and drainage of secretions.

adequate oxygenation of tissues by HBGs within clients normal limits.

3. Reveals presence of pulmonary congestion/ collection of secretion, indicating need for further intervention.

Collaborative: 1. Assisted with procedures as individually indicated (e.g., transfusion, phlebotomy, bronchoscopy.

Collaborative: 1. To improve respiratory function/ oxygen-carrying capacity.